Prioritizing areas for malaria control using geographical information system in Sonitpur district, Assam, India

Are malaria elimination efforts on right track? An analysis of gains achieved and challenges ahead

Background

Malaria causes significant morbidity and mortality each year. In the past few years, the global malaria cases have been declining and many endemic countries are heading towards malaria elimination. Nevertheless, reducing the number of cases seems to be easy than sustained elimination. Therefore to achieve the objective of complete elimination and maintaining the elimination status, it is necessary to assess the gains made during the recent years.

Main text

With inclining global support and World Health Organisation (WHO) efforts, the control programmes have been implemented effectively in many endemic countries. Given the aroused interest and investments into malaria elimination programmes at global level, the ambitious goal of elimination appears feasible. Sustainable interventions have played a pivotal role in malaria contraction, however drug and insecticide resistance, social, demographic, cultural and behavioural beliefs and practices, and unreformed health infrastructure could drift back the progress attained so far. Ignoring such impeding factors coupled with certain region specific factors may jeopardise our ability to abide righteous track to achieve global elimination of malaria parasite. Although support beyond the territories is important, but well managed integrated vector management approach at regional and country level using scrupulously selected area specific interventions targeting both vector and parasite along with the community involvement is necessary. A brief incline in malaria during 2016 has raised fresh perturbation on whether elimination could be achieved on time or not.

Conclusions

The intervention tools available currently can most likely reduce transmission but clearing of malaria epicentres from where the disease can flare up any time, is not possible without involving local population. Nevertheless maintaining zero malaria transmission and checks on malaria import in declared malaria free countries, and further speeding up of interventions to stop transmission in elimination countries is most desirable. Strong collaboration backed by adequate political and financial support among the countries with a common objective to eliminate malaria must be on top priority. The present review attempts to assess the progress gained in malaria elimination during the past few years and highlights some issues that could be important in successful malaria elimination.

Electronic supplementary material

The online version of this article (10.1186/s40249-019-0524-x) contains supplementary material, which is available to authorized users.

Distribution of Plasmodium spp. infection in asymptomatic carriers in perennial and low seasonal malaria transmission settings in West Africa

Background

Since 2000, substantial progress has been made in reducing malaria worldwide. However, some countries in West Africa remain a hotspot for malaria with all age groups at risk. Asymptomatic carriers of Plasmodium spp. are important sources of infections for malaria vectors and thus contribute to the anchoring of the disease in favourable eco-epidemiological settings. The objective of this study was to assess the asymptomatic malaria case rates in Korhogo and Kaedi, two urban areas in northern Côte d’Ivoire and southern Mauritania, respectively.

Methods

Cross-sectional surveys were carried out during the rainy season in 2014 and the dry season in 2015 in both settings. During each season, 728 households were randomly selected and a household-based questionnaire was implemented to collect demographic and epidemiological data, including of malaria preventive methods used in communities. Finger-prick blood samples were obtained for biological examination using microscopy and rapid diagnostic tests (RDTs).

Results

Overall, 2672 households and 15 858 consenting participants were surveyed. Plasmodium spp. infection was confirmed in 12.4% (n = 832) and 0.3% (n = 22) of the assessed individuals in Korhogo and Kaedi, respectively. In Korhogo, the prevalence of asymptomatic malaria was 10.5% (95% CI: 9.7–11.2) as determined by microscopy and 9.3% (95% CI: 8.6–10.0%) when assessed by RDT. In Kaedi, asymptomatic malaria prevalence was 0.2% (95% CI: 0.1–0.4%) according to microscopy, while all RDTs performed were negative (n = 8372). In Korhogo, asymptomatic malaria infection was significantly associated with age and season, with higher risk within the 5–14 years-old, and during the rainy season. In Kaedi, the risk of asymptomatic malaria infection was associated with season only (higher during the dry season; crude OR (cOR): 6.37, 95% CI: 1.87–21.63). P. falciparum was the predominant species identified in both study sites representing 99.2% (n = 825) in Korhogo and 59.1% (n = 13) in Kaedi. Gametocytes were observed only in Korhogo and only during the rainy season at 1.3% (95% CI: 0.7–2.4%).

Conclusions

Our findings show a low prevalence of clinical malaria episodes with a significant proportion of asymptomatic carriers in both urban areas. National policies for malaria infections are focused on treatment of symptomatic cases. Malaria control strategies should be designed for monitoring and managing malaria infections in asymptomatic carriers. Additional measures, including indoor residual spraying, effective use of long-lasting insecticidal nets is strongly needed to reduce the number of Plasmodium spp. infections in Korhogo and Kaedi.

Electronic supplementary material

The online version of this article (10.1186/s40249-018-0412-9) contains supplementary material, which is available to authorized users.

Passive case detection of malaria in Ratanakiri Province (Cambodia) to detect villages at higher risk for malaria

BACKGROUND

Cambodia reduced malaria incidence by more than 75% between 2000 and 2015, a target of the Millennium Development Goal 6. The Cambodian Government aims to eliminate all forms of malaria by 2025. The country's malaria incidence is highly variable at provincial level, but less is known at village level. This study used passive case detection (PCD) data at village level in Ratanakiri Province from 2010 to 2014 to describe incidence trends and identify high-risk areas of malaria to be primarily targeted towards malaria elimination.

METHODS

In 2010, the Cambodian malaria programme created a Malaria Information System (MIS) to capture malaria information at village level through PCD by village malaria workers and health facilities. The MIS data of Ratanakiri Province 2010-2014 were used to calculate annual incidence rates by Plasmodium species at province and commune levels. For estimating the trend at provincial level only villages reporting each year were selected. The communal incidences and the number of cases per village were visualized on a map per Plasmodium species and per year. Analysis of spatial clustering of village malaria cases by Plasmodium species was performed by year.

RESULTS

Overall, malaria annual incidence rates per 1000 inhabitants decreased from 86 (2010) to 30 (2014). Falciparum incidence decreased (by 79% in 2014 compared to 2010; CI 95% 76-82%) more rapidly than vivax incidence (by 19% in 2014 compared to 2010; CI 95% 5-32%). There were ten to 16 significant spatial clusters each year. Big clusters tended to extend along the Cambodian-Vietnamese border and along the Sesan River. Three clusters appeared throughout all years (2010-2014): one with 21 villages appeared each year, the second shrunk progressively from 2012 to 2014 and the third was split into two smaller clusters in 2013 and 2014.

CONCLUSION

The decline of malaria burden can be attributed to intensive malaria control activities implemented in the areas: distribution of a long-lasting insecticidal net per person and early diagnosis and prompt treatment. Dihydro-artemisinin piperaquine was the only first-line treatment for all malaria cases. No radical treatment with primaquine was provided for Plasmodium vivax cases, which could explain the slow decrease of P. vivax due to relapses. To achieve malaria elimination by 2025, priority should be given to the control of stable malaria clusters appearing over time.

Evaluation of Insecticides Susceptibility and Malaria Vector Potential of Anopheles annularis s.l. and Anopheles vagus in Assam, India

During the recent past, development of DDT resistance and reduction to pyrethroid susceptibility among the malaria vectors has posed a serious challenge in many Southeast Asian countries including India. Current study presents the insecticide susceptibility and knock-down data of field collected Anopheles annularis sensu lato and An. vagus mosquito species from endemic areas of Assam in northeast India. Anopheles annularis s.l. and An. vagus adult females were collected from four randomly selected sentinel sites in Orang primary health centre (OPHC) and Balipara primary health centre (BPHC) areas, and used for testing susceptibility to DDT, malathion, deltamethrin and lambda-cyhalothrin. After insecticide susceptibility tests, mosquitoes were subjected to VectorTest™ assay kits to detect the presence of malaria sporozoite in the mosquitoes. An. annularis s.l. was completely susceptible to deltamethrin, lambda-cyhalothrin and malathion in both the study areas. An. vagus was highly susceptible to deltamethrin in both the areas, but exhibited reduced susceptibility to lambda-cyhalothrin in BPHC. Both the species were resistant to DDT and showed very high KDT50 and KDT99 values for DDT. Probit model used to calculate the KDT50 and KDT99 values did not display normal distribution of percent knock-down with time for malathion in both the mosquito species in OPHC (p<0.05) and An. vagus in BPHC (χ2 = 25.3; p = 0.0), and also for deltamethrin to An. vagus in BPHC area (χ2 = 15.4; p = 0.004). Minimum infection rate (MIR) of Plasmodium sporozoite for An. vagus was 0.56 in OPHC and 0.13 in BPHC, while for An. annularis MIR was found to be 0.22 in OPHC. Resistance management strategies should be identified to delay the expansion of resistance. Testing of field caught Anopheles vectors from different endemic areas for the presence of malaria sporozoite may be useful to ensure their role in malaria transmission.

ID-Viewer: a visual analytics architecture for infectious diseases surveillance and response management in Pakistan

OBJECTIVES

Globally, disease surveillance systems are playing a significant role in outbreak detection and response management of Infectious Diseases (IDs). However, in developing countries like Pakistan, epidemic outbreaks are difficult to detect due to scarcity of public health data and absence of automated surveillance systems. Our research is intended to formulate an integrated service-oriented visual analytics architecture for ID surveillance, identify key constituents and set up a baseline for easy reproducibility of such systems in the future.

STUDY DESIGN

This research focuses on development of ID-Viewer, which is a visual analytics decision support system for ID surveillance. It is a blend of intelligent approaches to make use of real-time streaming data from Emergency Departments (EDs) for early outbreak detection, health care resource allocation and epidemic response management.

METHODS

We have developed a robust service-oriented visual analytics architecture for ID surveillance, which provides automated mechanisms for ID data acquisition, outbreak detection and epidemic response management. Classification of chief-complaints is accomplished using dynamic classification module, which employs neural networks and fuzzy-logic to categorize syndromes. Standard routines by Center for Disease Control (CDC), i.e. c1-c3 (c1-mild, c2-medium and c3-ultra), and spatial scan statistics are employed for detection of temporal and spatio-temporal disease outbreaks respectively. Prediction of imminent disease threats is accomplished using support vector regression for early warnings and response planning. Geographical visual analytics displays are developed that allow interactive visualization of syndromic clusters, monitoring disease spread patterns, and identification of spatio-temporal risk zones.

RESULTS

We analysed performance of surveillance framework using ID data for year 2011-2015. Dynamic syndromic classifier is able to classify chief-complaints to appropriate syndromes with high classification accuracy. Outbreak detection methods are able to detect the ID outbreaks in start of epidemic time zones. Prediction model is able to forecast dengue trend for 20 weeks ahead with nominal normalized root mean square error of 0.29. Interactive geo-spatiotemporal displays, i.e. heat-maps, and choropleth are shown in respective sections.

CONCLUSION

The proposed framework will set a standard and provide necessary details for future implementation of such a system for resource-constrained regions. It will improve early outbreak detection attributable to natural and man-made biological threats, monitor spatio-temporal epidemic trends and provide assurance that an outbreak has, or has not occurred. Advanced analytics features will be beneficial in timely organization/formulation of health management policies, disease control activities and efficient health care resource allocation.

Preliminary in vitro antiplasmodial activity of Aristolochia griffithii and Thalictrum foliolosum DC extracts against malaria parasite Plasmodium falciparum

Background

Resistance development in human malaria parasites against commonly used antimalarial drugs has necessitated the scientific exploration of traditionally used antimalarial plants. Plant derivatives have been used for curing malaria historically. The present study involves in vitro evaluation of two medicinally important plants Aristolochia griffithii and Thalictrum foliolosum DC used in antimalarial chemotherapy by the tribes of northeast India.

Method

Chloroform, ethyl acetate and n–butanol extracts of Aristolochia griffithii and Thalictrum foliolosum DC were evaluated in vitro against chloroquine sensitive (SS) and chloroquine resistance strains (RS) of P. falciparum. The tests were conducted following WHO standard method and the inhibition of parasite (IC₅₀) was calculated.

Results

In A. griffithii, the IC₅₀ value for ethyl acetate extracts against SS was 6.2 ± 0.02 μg/ml and found to be lower than chloroform extracts, which exhibited an IC₅₀ value of 14.1 ± 0.1 μg/ml (t = 191.1; p < 0.0001). The IC₅₀ values of both chloroform and ethyl acetate extracts for RS were higher as compared to the SS (p < 0.0001). In T. foliolosum DC the IC₅₀ concentration of chloroform extracts for SS and RS were 0.5 ± 0.0 and 1.1 ± 0.0 μg/ml respectively (t = 54.2; p < 0.0001).

Conclusion

The present findings, although preliminary, but scientifically demonstrate that identification and isolation of active compounds of these two plant materials and testing against different Plasmodium species could lead to the development of potential antimalarial drugs for future.

Absence of asymptomatic malaria in a cohort of 133 individuals in a malaria endemic area of Assam, India

BACKGROUND

Malaria in northeast India affects children and adults annually. The number of malaria cases reported has declined over the past few years. Nevertheless, it is not clear whether there is an actual decline in parasitaemia or whether asymptomatic malaria infections are on the rise, especially in forested and forest-fringed areas. Asymptomatic malaria forms a parasite reservoir that acts as an epicentre for malaria spread during high-transmission season. Therefore it is important to understand the quantum of asymptomatic malaria infections among the vulnerable population.

METHOD

Four forest fringed historically malaria endemic villages were selected for the study. A total of 133 individuals without a fever history in the past four weeks were tested for malaria parasite using rapid diagnostic test (RDT), microscopy and polymerase chain reaction (PCR) assay during January - February 2014. Indoor resting Anopheles vectors were collected, identified and tested for sporozoite using VectorTest™ panel assay during October 2013 to March 2014, which is a low transmission season for malaria. Social and demographic data were recorded during the study.

RESULTS

Mean age (± SEM) of the participants was 16.1 ± 1.2 years (95 % CI: 13.8-18.4). All participants (100 %) reported to use mosquito nets. Altogether, 43.6 % of participants had education below primary level and only 9 % reported a travel history during the past four weeks. All RDT, microscopy and PCR assays were found negative indicating no asymptomatic malaria parasitaemia. Seven known malaria vector species namely, Anopheles nivipes, An. minimus, An. annularis, An. vagus, An. aconitus, An. philippinensis and An. culicifacies, were recorded in the present study. VectorTest™ sporozoite panel assay conducted on 45 pools (N = 224) of vector mosquitoes were found negative for Plasmodium sporozoite.

DISCUSSION

Northeastern states of India report asymptomatic malaria parasitemia along with high malaria transmission. An. minimus and An. dirus are recognised as efficient vectors, but An. culicifacies, An. philippinensis and An. annularis also play role in malaria transmission. Currently all participants were found negative for asymptomatic malaria, however the small sample size may restrict the scope of present results to the population living in more remote areas.

CONCLUSION

No cases of asymptomatic malaria infections parasitaemia was found in the present study conducted during a low transmission season indicating that asymptomatic malaria parasitaemia may not be prevalent in the region. Mosquito specimens were tested negative for the malaria sporozoites. Study findings encourage the ongoing malaria intervention efforts and recommends similar investigations in different ecological areas involving large populations.

Socio-economic, epidemiological and geographic features based on GIS-integrated mapping to identify malarial hotspots

Background

Malaria is a major health problem in the tropical and subtropical world. In India, 95% of the population resides in malaria endemic regions and it is major public health problem in most parts of the country. The present work has developed malaria maps by integrating socio-economic, epidemiology and geographical dimensions of three eastern districts of Uttar Pradesh, India. The area has been studied in each dimension separately, and later integrated to find a list of vulnerable pockets/villages, called as malarial hotspots.

Methods

The study has been done at village level. Seasonal variation of malaria, comparison of epidemiology indices and progress of the medical facility were studied. Ten independent geographical information system (GIS) maps of socio-economic aspects (population, child population, literacy, and work force participation), epidemiology (annual parasitic index (API) and slides collected and examined) and geographical features (settlement, forest cover, water bodies, rainfall, relative humidity, and temperature) were drawn and studied. These maps were overlaid based on computed weight matrix to find malarial hotspot.

Results

It was found that the studied dimensions were inter-weaving factors for malaria epidemic and closely affected malaria situations as evidenced from the obtained correlation matrix. The regions with water logging, high rainfall and proximity to forest, along with poor socio-economic conditions, are primarily hotspot regions. The work is presented through a series of GIS maps, tables, figures and graphs. A total of 2,054 out of 8,973 villages studied were found to be malarial hotspots and consequently suggestions were made to the concerned government malaria offices.

Conclusion

With developing technology, information tools such as GIS, have captured almost every field of scientific research especially of vector-borne diseases, such as malaria. Malarial mapping enables easy update of information and effortless accessibility of geo-referenced data to policy makers to produce cost-effective measures for malaria control in endemic regions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-015-0685-4) contains supplementary material, which is available to authorized users.

Multi-insecticide susceptibility evaluation of dengue vectors Stegomyia albopicta and St. aegypti in Assam, India

BACKGROUND

Dengue is rapidly expanding mosquito-borne viral infection globally facing operational challenges due to insecticide resistance in dengue vectors. We have studied the susceptibility status of potential dengue vectors St. albopicta and St. aegypti to the commonly used insecticides.

METHODS

Stegomyia larval bioassays were carried out to determine LC10, LC50 and LC99 values and resistance ratios (RR50 and RR99) for temephos. Adult susceptibility bioassay to 4% DDT, 0.05% deltamethrin, 5% malathion was assessed following standard procedure to determine the corrected mortality. Knock-down times (KDT50 and KDT99) were estimated and the knock-down resistance ratios (KRR50 and KRR99) were calculated.

RESULTS

St. albopicta wild population (WP) of Sotia was resistant to temephos as the LC99 value was 0.12 mg/l and found to be 2.3 fold high than the reference population (RP). St. aegypti WP of Borgong, Kusumtola and Serajuli displayed a RR99 of 2.5, 5.4 and 4.5 respectively suggesting high level of resistance to temephos. Results suggested that both St. albopicta and St. aegypti WP were fully resistant to DDT (mortality < 90%) in all the study locations. Both the species were completely susceptible to deltamethrin and malathion (corrected mortality > 98%), except for St. albopicta at Sotia which displayed low level of resistance to malathion (corrected mortality =95.4%). The estimated KDT values for both the species indicated high level of knock-down resistance to DDT and susceptibility to deltamethrin.

CONCLUSION

WP of both the dengue vectors showed varied response to temephos, while resistant to DDT and completely susceptible to deltamethrin. Both the species were susceptible to malathion at majority of the testing sites. Current results strongly advocate that DDT is no longer effective against dengue vectors, while thorough monitoring of malathion susceptibility in geographical area at dengue risk is inexorable to ascertain whether or not the resistance to malathion is focal. Information generated herein may be useful in better planning and implementing in dengue control strategy using insecticides.

Genetic polymorphism and amino acid sequence variation in Plasmodium falciparum GLURP R2 repeat region in Assam, India, at an interval of five years

Background

The R2 repeat region of GLURP has been reported as a good genetic marker for Plasmodium falciparum genotyping. Proper knowledge of the extent and nature of P. falciparum genetic diversity using highly immunogenic R2 repeat region in malaria-endemic areas is a crucial element to understand various aspects related to immunity acquisition and disease pathogenesis.

Methods

Population diversity of P. falciparum GLURP and amino acid sequence repeats in GLURP R2 region was studied in malaria-endemic Assam state, northeast India and compared at an interval of five years during 2005 (Group-A) and 2011 (Group-B).

Results

Of the 66 samples, a total of 55 samples showed positive PCR bands for GLURP R2 region and altogether ten types of alleles with size ranging from 501 bp to 1,050 bp (50 bp bin) were observed and coded as genotypes I-X. In Group-A (n = 29), 24 samples were found infected with single, four with double and one with triple P. falciparum genotype, while in Group-B (n = 26), single genotype was found in 23 samples, double in two samples and triple in one sample. Genotype IV showed significant increase (p = 0.002) during 2011 (Group-B). Genotypes I to V were more common in Group-B (62%), however genotypes VI to X were more frequently distributed in Group-A. The expected heterozygosity was found slightly higher in Group-A (H_E = 0.87) than Group-B (H_E = 0.85), whereas multiplicity of infection (MOI) in Group-A (MOI = 1.21 ± 0.49) and Group-B (MOI = 1.12 ± 0.43) did not display significant variation. The amino acid repeat sequence unit (AAU) DKNEKGQHEIVEVEEILPE (called ‘a’) was more frequent in the well-conserved part of R2 repeat region.

Conclusion

The present study is the first extensive study in India which has generated substantial data for understanding the type and distribution of naturally evolved genetic polymorphism at amino acid sequence level in GLURP R2 repeat region in P. falciparum. There was decrease in the PCR amplicon size as well as the number of AAU [amino acid repeat unit] in Group-B displaying the bottleneck effect. The present study described a new type of AAU ‘d’ which varied from the other previous known AAUs.

Electronic supplementary material

The online version of this article (doi:10.1186/1475-2875-13-450) contains supplementary material, which is available to authorized users.

Socio-economic determinants for malaria transmission risk in an endemic primary health centre in Assam, India

Background

Malaria is a major cause of morbidity and mortality in Northeast India. As there is limited information available on the potential influence of socio-economic variables on malaria risk, the present study was conducted to assess the influence of demographic factors, the socio-economic status, and knowledge, awareness and education on malaria occurrence.

Methods

Demographics, malaria knowledge and socio-economic variables were collected in four randomly selected health sub-centres of the Orang primary health centre in the Udalguri district, Assam and the association of malaria occurrence with different variables were analysed. The trend of malaria occurrence for different income groups, proximity to health centres and number of mosquito bites per day was also determined using the chi-square test. Relative risk (RR) for gender, house type, knowledge and use of bed nets was determined using Katz approximation.

Results

Out of the 71 household heads interviewed, 70.4% (50/71) were males. About half (54.9%, 39/71) of the participants had a history of malaria in the last two years, of which 64.1% (25/39) were males, while 35.9% (14/39) were females (χ² = 5.13; p = 0.02; RR = 1.79). Of the total population surveyed, 49.3% lived in bamboo houses and 35.2% lived at a distance of >3 km from the nearest health centre. The number of participants who had a history of malaria decreased with an increasing monthly income (p < 0.0001). Malaria occurrence was higher among the households living in bamboo houses (69.2%), as compared to Kucha houses (20.5%) and Pucca houses (10.3%). No significant association was observed between education level and malaria occurrence (p = 0.93). The participants who did not use bed nets regularly reported a high occurrence of malaria infection as compared to those who used bed nets everyday (p < 0.0001).

Conclusions

Lower income, house type, distance to health sub-centre, knowledge and awareness about malaria, number of mosquito bites per day and use of bed nets were positively associated with malaria occurrence. Increasing the number of health sub-centres close to rural areas, improving the economic status and increasing awareness about malaria prevention measures will thus help to reduce malaria-associated morbidities.

Mobile technologies and geographic information systems to improve health care systems: a literature review

Background

A growing body of research has employed mobile technologies and geographic information systems (GIS) for enhancing health care and health information systems, but there is yet a lack of studies of how these two types of systems are integrated together into the information infrastructure of an organization so as to provide a basis for data analysis and decision support. Integration of data and technical systems across the organization is necessary for efficient large-scale implementation.

Objective

The aim of this paper is to identify how mobile technologies and GIS applications have been used, independently as well as in combination, for improving health care.

Methods

The electronic databases PubMed, BioMed Central, Wiley Online Library, Scopus, Science Direct, and Web of Science were searched to retrieve English language articles published in international academic journals after 2005. Only articles addressing the use of mobile or GIS technologies and that met a prespecified keyword strategy were selected for review.

Results

A total of 271 articles were selected, among which 220 concerned mobile technologies and 51 GIS. Most articles concern developed countries (198/271, 73.1%), and in particular the United States (81/271, 29.9%), United Kingdom (31/271, 11.4%), and Canada (14/271, 5.2%). Applications of mobile technologies can be categorized by six themes: treatment and disease management, data collection and disease surveillance, health support systems, health promotion and disease prevention, communication between patients and health care providers or among providers, and medical education. GIS applications can be categorized by four themes: disease surveillance, health support systems, health promotion and disease prevention, and communication to or between health care providers. Mobile applications typically focus on using text messaging (short message service, SMS) for communication between patients and health care providers, most prominently reminders and advice to patients. These applications generally have modest benefits and may be appropriate for implementation. Integration of health data using GIS technology also exhibit modest benefits such as improved understanding of the interplay of psychological, social, environmental, area-level, and sociodemographic influences on physical activity. The studies evaluated showed promising results in helping patients treating different illnesses and managing their condition effectively. However, most studies use small sample sizes and short intervention periods, which means limited clinical or statistical significance.

Conclusions

A vast majority of the papers report positive results, including retention rate, benefits for patients, and economic gains for the health care provider. However, implementation issues are little discussed, which means the reasons for the scarcity of large-scale implementations, which might be expected given the overwhelmingly positive results, are yet unclear. There is also little combination between GIS and mobile technologies. In order for health care processes to be effective they must integrate different kinds of existing technologies and data. Further research and development is necessary to provide integration and better understand implementation issues.